HCRA Hospital Conference

November 15, 2011

Webinar Q & A´s

Question Number

Question

Answer

1

How do you handle the fact that the payors are paying the surcharge on copays and deductibles differently within their plans? Is the state considering requiring electing payors to pay that portion direct to the state?

The Department is aware of the problems related to the copay and deductible issue and the difficulty the providers face providing documentation to support their position during audit. The Department is currently working with GNYHA, HANYS and the payors to try and resolve the issue.

2

Does GME liability apply to foreign payors?

The GME applies to inpatient claims if the foreign insurer is:

non-electing,

providing inpatient coverage, and

is either an accident and health policy, or considered to be deemed an accident and health policy based on U.S. insurance standards, or a self funded plan, as deemed by U.S. standards.

3

Is revenue for non-physicians employed by a hospital, such as nurse practitioners, dentists, and physician assistants, subject to surcharge?

Yes. The exemption for physician revenue only applies to those physicians who are "M.D.´s" or "D.O.´s" In addition, the bill must be discretely billed, thus excluded from the billing provider´s institutional rates for services rendered.

4

Will the state post the payors election for the co-pays or at least let HANYS post it on our web site?

The Department is not prepared to post the list at this time.

5

Could you please verify that Medicaid spend downs are subject to surcharge?

In cases where the patient is not currently Medicare eligible (dual eligibility), surcharges are applicable to revenue received for claims paid and applied towards a patient's Medicaid spend down. The person is considered self pay at that time, and the hospital is receiving its revenue from the patient, not Medicaid yet.

6

You mentioned that Medigap payments are not surcharge assessable, what about the Medicare Secondary payor payments?

It depends. If the plan is making payment for a service that was denied by Medicare, due to either exhaustion of benefits, or an uncovered service, and therefore Medicare has not made any payment for the service, the surcharge applies, at rates based on their election status. If Medicare covered the service, but its payment did not fully pay for the service, and the secondary payor is making payment to complete the payment for the service, surcharges do not apply. The Public Health Law exempts surcharges on revenue received for services provided to those eligible to receive payments as beneficiaries of Medicare. In this situation, the patient is considered eligible to receive payments as a beneficiary of Medicare because Medicare did make some payment for the service.

7

What is the process for recouping surcharge overpayments based on a finalized audit?

The provider is to recoup the overpayment by reducing or eliminating their payment for liabilities due as calculated on their next submission of their monthly Public Goods Pool report. If their unadjusted liability in the report exceeds the amount of the audit overpayment, the balance of the liability must be submitted. See below how where to send the payment and a copy of the report.

If the unadjusted report liability for your next submission is less than the audit overpayment, the provider can only reduce the liability by the amount that equals the monthly report liability, or, to reduce to zero. The electronic system will not allow reports with a credit balance calculated. In that case, the provider can continue to reduce the liability reported on future reports until the audit overpayment is fully recouped.

In either case, the auditee must send the payment, (if applicable), and a copy of the submitted report directly to the Department, along with a short note indicating that due to the outcome of their audit, the payment for this report submission is less than liability calculated, or, a statement indicating that there is no payment for the calculated liability because of a recoupment of the audit overpayment. The Department will be responsible for notifying the Pool that the payment has been received, or will not be received for the submitted report, due to an audit overpayment. This will ensure that this report is recorded properly. Failure to submit this information to the Department may result in non-recognition of the report and cause your facility to be considered delinquent.

8

If I am understanding correctly it is at the time of being selected for audit that we are given the IT specifications that are needed for audit. Why can't this information be shared and developed similar to SPARCS data collections and before being selected for audit?

See answers for Questions 9 and 10

9

If providers are notified in advance, all data needed for these audits could be already available. It takes a lot of time to capture data from IT systems to meet these requests.

The Department tries to give the provider at least 60 days prior to starting the audit to accumulate their data. We are open to discussing the amount of additional time needed to gather data for audits with both GNYHA and HANYS.

10

Can everyone be sent a copy of the data request packet through HANYS, or at least have it posted on the DOH web site?

The Department is not prepared to post the data blueprint at this time.